What is the recommended dose and treatment instructions for a patient with oral thrush, specifically for nystatin (antifungal medication) or clotrimazole (antifungal medication)?

Nystatin Dosing and Instructions for Oral Thrush

For mild oral thrush, use nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, swishing the medication in your mouth as long as possible before swallowing, though be aware that clotrimazole troches or fluconazole are more effective options. 1, 2

Standard Nystatin Dosing

Adults and Children:

• Dose: 4-6 mL (400,000-600,000 units) four times daily 1, 2
• Administration: Place half the dose in each side of the mouth, swish thoroughly for as long as possible (ideally at least 2 minutes), then swallow the medication 3, 2
• Duration: 7-14 days, continuing for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida 1, 2
• Timing: Ideally administer after meals and before bedtime 3

Infants:

• Dose: 2 mL (200,000 units) four times daily 2
• Administration: Use dropper to place half the dose in each side of mouth, avoid feeding for 5-10 minutes 2
• Premature/Low Birth Weight: 1 mL four times daily is effective 2

Alternative Nystatin Formulation:

• Nystatin pastilles: 1-2 pastilles (200,000 units each) four times daily for 7-14 days 1, 3

Critical Treatment Algorithm by Disease Severity

For Mild Disease (First-Line Options in Order of Preference):

1. Clotrimazole troches 10 mg five times daily for 7-14 days - superior convenience and efficacy compared to nystatin 1, 3
2. Miconazole mucoadhesive buccal tablet 50 mg once daily for 7-14 days - most convenient once-daily option 1, 3
3. Nystatin suspension (as detailed above) - acceptable but lower efficacy 1, 3

For Moderate to Severe Disease:

• Oral fluconazole 100-200 mg daily for 7-14 days is mandatory - this is the gold standard with 100% clinical cure rates compared to nystatin's 32-54% cure rates 1, 3, 4

Important Caveats and Pitfalls

Nystatin Limitations:

• Nystatin has significantly lower efficacy than fluconazole, with clinical cure rates of only 32-54% versus 100% with fluconazole in comparative studies 3, 4
• Nystatin should NOT be used as first-line for moderate-to-severe disease or in immunocompromised patients 3
• Topical nystatin is completely inadequate for esophageal candidiasis - systemic therapy is required 3, 5

When to Switch Therapy:

• If no clinical response occurs within 48-72 hours, switch to fluconazole rather than extending nystatin duration 5
• For fluconazole-refractory disease, use itraconazole solution 200 mg once daily, posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily, or voriconazole 200 mg twice daily 1, 3

Special Populations:

• HIV-infected patients: Antiretroviral therapy is more important than antifungal choice for reducing recurrence rates 1, 3
• Recurrent infections: Fluconazole 100 mg three times weekly for chronic suppression 1, 3
• Denture-related candidiasis: Denture disinfection must accompany any antifungal therapy 1, 3

Adjunctive Measures

• Apply white soft paraffin ointment to lips every 2 hours 3
• Use mucoprotectant mouthwash three times daily 3
• Use antiseptic oral rinse twice daily 3
• Consider benzydamine hydrochloride rinse every 3 hours for symptom relief 3